PN Mental Health Online Practice 2023 A

A nurse is collectine data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect?

Projects blame onto others CORRECT

Click to highlight the information in the client's medical record that indicates the client's condition is deteriorating. To deselect a piece of information, click on the information again.

QT prolongation Exercise regimen Hematemesis BMI

Select the 6 findings found in the client's medical record that are indications of an exacerbation of a personality disorder.

Steals money from parents to cover credit card charges anxious if left alone Hypersexualization married multiple times incidences fo self-injury physical altercations

A nurse is reviewing the medical record of a female client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

WBC count

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching?

the voices you have been hearing should decrease

A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first?

"Are you experiencing feelings of hopelessness?"

A nurse is reinforcing teaching with a newly admitted client who has generalized anxiety disorder. Which of the following statements should the nurse make?

A. "We will demonstrate for you how to use relaxation techniques."

A nurse observes a client who has schizophrenia and exhibits akathisia. Which of the following interventions should the nurse implement?

Administer an antiparkinsonian agent. The nurse should anticipate that an antiparkinsonian agent will be administered for akathisia, which is an adverse effect of an antipsychotic medication for the treatment of schizophrenia.

A nurse is reinforcing teaching with the caregiver of a client who has histrionic personality disorder. Which of the following manifestations should the nurse tell the caregiver to expect?

attention seeking behavior

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

elevated blood pressure

A nurse in a mental health facility is caring for a client who is becoming agitated, Which of the following, actions should the nurse take first?

offer diversionary activities

A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few moments later, the client cheerfully states, "Now, here is my favorite social worker!" The nurse should identify that the client is using which of the following defense mechanisms?

reaction formation

A nurse is caring for an adult client who is about to undergo screening with the mental status examination (MSE). The client asks about the purpose of this test. Which of the following responses should the nurse make?

"This test will give us information about how you remember things."

A nurse is collecting data from a client who says they use alcohol "to cope with stress." Which of the following questions should the nurse ask?

"What daily activities are disrupted because of your alcohol consumption?"

A nurse in an inpatient unit is assisting with a group therapy session. During the session, a client begins to shout and use aggressive language. Which of the following statements should the nurse make to the client?

"When you raise your voice, it makes me feel uncomfortable and unsafe."

A nurse is reinforcing teaching with the caregiver of an adolescent who has amphetamine use disorder. The nurse should identify that which of the following statements by the caregiver indicates an understanding of the teaching?

"Dilated pupils are a sign that my child is using amphetamines."

A nurse is collecting data from a client who is having difficulty coping with the death of their child. Which of the following questions by the nurse is the priority?

"Do you think about harming yourself?"

A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make?

"Have you considered participating in a sport to help control your aggression?"

A nurse is caring for a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective?

"I drink less alcohol in a day while taking naltrexone." Clients taking naltrexone have a decreased craving for alcohol and experience decreased pleasurable effects from alcohol consumption. Although the goal for most clients who have alcohol use disorder is to maintain abstinence, clients who ingest alcohol while taking this medication often drink less per day.

A nurse in a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?

"The consent form should have the name of the provider who is performing the procedure on the form."

A charge nurse is discussing the use of restraints with a newly licensed nurse. Which of the following statements made by the newly licensed nurse demonstrates an understanding?

"The provider should make an in-person evaluation of the client within 1 hr of initiating the restraints."

A nurse is preparing to administer haloperidol 3 mg IM to a client. Available is haloperidol solution 5 mg/mL. How many mL should the nurse plan to administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

.6

A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia?

Apathy Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings.

A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider's recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client's decision?

Autonomy *The nurse is demonstrating the principle of autonomy by respecting and supporting the client's right to make decisions about her treatment.

A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy?

Demonstrating performing hand hygiene at appropriate times. *This action is an example of modeling, which is a strategy that allows the client to see another person perform the expected behavior.

A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next?

Determine the benefits and consequences of respecting the client's medical decisions.

A nurse is caring for a client who has visible injuries as a result of partner violence. Which of the following actions should the nurse take?

Encourage the client to develop a safety plan. R: The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary.

A nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of the therapeutic nurse-client relationship?

Evaluate the client's progress toward meeting their goals.

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Haloperidol 2 mg IM: anticipated Hold next dose of buspirone: contraindicated Request change of diet to mechanical soft: nonessential Request prescription for digoxin 1 mg IV bolus STAT: contraindicated Calmly approach client and state," You seem agitated. Let's sit quietly and talk about it": anticipated

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following intervention: should the nurse include to improve the client's nutritional status?

Have finger foods available for the client in a quiet area.

Complete the following sentence by using the list of options.

The client is at greatest risk for violent behavior an evidenced by the client's agitation.

Complete the following sentence by using the lists of options.

The client is at risk for developing violent behavior as evidenced by the client's increased agitation.

A nurse is collecting data from a client who has dementia and whose family expresses concern about their increasing "memory problems." Which of the following findings should the nurse identify as the priority?

The client sometimes wanders from the house.

A nurse in a provider's office is collecting data from an older adult client whose adult child reports that the client "seems confused and can't seem to remember much." Which of the following findings should lead the nurse to suspect delirium?

The client's level of consciousness changes during the interview

Complete the following sentence by using the lists of options.

The first action the nurse should take is to address the client's risk for cardiovascular injury due to the client's constant psychomotor activity

A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findings should the nurse identify as manifestations of bulimia nervosa? (Select all that apply.)

Tooth erosion Tooth erosion is a manifestation of bulimia nervosa that results from self-induced vomiting. Hand calluses Hand calluses are a manifestation of bulimia nervosa that results from self-induced vomiting. Hypokalemia Hypokalemia is a manifestation of bulimia nervosa that results from volume depletion due to self-induced vomiting or excessive diuretic and laxative use.

After reviewing the client's medical record, the nurse should report which of the following findings to the provider? Select the 5 findings that should be reported.

When analyzing cues, the nurse should identify that the client's blood pressure. heart rate, temperature, speech pattern, and hallucinations are findings the nurse should report to the provider. The client's blood pressure is above the expected reference range, indicating hypertension. The heart rate is above the expected reference range, indicating tachycardia, The temperature is above the expected reference range, indicating a fever. The client is exhibiting a change in speech pattern, including rapid and rambling speech. Also, hallucinations and delusions are manifestations which can indicate alcohol withdrawal delirium, or delirium tremens (DT). DT is an emergent condition that can be fatal. Therefore, the nurse should report these findings to the provider.

A nurse is planning to collect data from a group of clients. The nurse should expect that which of the following clients is likely to exhibit speech pattern alterations?

a client who has schizophrenia

For each potential finding, dick to specify if the finding indicates the client's condition has improved, not changed, or has declined.

Client attempts to bite nursing staff when offered water is an indication that the client's condition has declined. The client is exhibiting worsening aggressive and violent behavior by attempting to bite nursing staff members. Client follows nurse's instructions is an indication that the client's condition has improved. The client is exhibiting control over their behavior and is able to follow instructions. Client is silent and glaring at staff is an indication that the client's condition has not changed. The client is still exhibiting agitation and nonverbal aggressive behaviors. Client verbalizes precipitating factors that lead to violent outburst is an indication that the client's condition has improved. The client is able to verbalize and identify factors that contributed to their violent behavior.

A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of group therapy?

Confidentiality

A nurse is contributing to the plan of care for a client who has an anxiety disorder. Which of the following interventions should the nurse recommend be included in the plan?

Help the client to identify situations that trigger his anxiety.

A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium?

Hepatic failure *Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke.

A nurse is monitoring the nutritional status of a client who has bulimia nervosa. The nurse should monitor the client for which of the following complications?

Hyponatremia The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use.

A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home, Which of the following actions should the nurse instruct the parent to take?

Initiate a point system for the child

The nurse is caring for the client who has been placed in mechanical restraints and seclusion. Which of the following actions should the nurse take? Select all that apply.

Maintain continuous observation of the client while in restraints is correct Conduct debriefing with the client and other staff is correct.

A nurse in an inpatient mental health unit is supervising a group of clients in the unit's dayroom. The nurse fails to respond to the escalating. behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable?

Negligence

A nurse in a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?

Offer liquid supplements to the client. *The nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when he is first admitted.

For each potential provider's prescription, click to specify if the prescribed therapy is expected for obsessive-compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than 1 disease process.

Systematic desensitization is an expected therapy for obsessive-compulsive disorder. Validation therapy is an expected therapy for dementia. Dialectical behavior therapy is an expected therapy for borderline personality disorder. Donepezil 5 mg PO daily is an expected therapy for dementia. Fluoxetine 20 mg PO daily is an expected therapy for obsessive-compulsive disorder and borderline personality disorder.

A nurse in a long-term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The din appears upset and asks the nurse when their partner will visit again. The nurse states, "It seems like you are feeling lonely. Let's take outside and talk." Which of the following communication strategies is the nurse using?

Validation therapy